Wednesday, March 30, 2011

Family planning means controlling the size of your family to one with the number of children you are able to feed, educate and care for in general. Rwanda has several reasons to promote family planning. One of our most important targets right now is the fight against maternal and child mortality – this is a substantial challenge for the health sector in Rwanda. We know that birth spacing of fewer than two years is linked with a child mortality of 186 deaths for 1,000 live birth but if we manage to convince families to have birth spacinf of 4 years the child mortality will reduce to 65 deaths for 1,000 births. With respect to maternal deaths, we have the evidence that shows that a birth spacing of 3 years reduces maternal mortality by 45%.

Another important reason to promote family planning is that our economic development needs it. For example, the most recent national demographic and health survey, in 2005, shows that Rwanda has a fertility rate of 5.5. With this fertility rate we will count 21.5 million Rwandans (up from apprxomiately 11 million now) by 2035. Since we have a very young population, even if we reduce dramatically the fertility rate to 2.3 children per woman we shall still have a population of 16 million Rwandans by 2035. In not reducing the population growth we are at risk of having huge consequences on many other sectors in addition to that of health. For example, in the education sector, we have fewer than 30,000 teachers in primary school. If we continue at the same fertility rate, by 2035 we will have 3.4 million children in primary school in need of more than 76,000 teachers. Even if we reduce the fertility rate to 2.3 we will have 2 million children in primary schools in need of 46,000 teachers. This second scenario is not ideal, but certainly would be better. Fewer children in the classroom will allow us to train them better, with higher quality and better trained teachers. In other sectors, the growth of the population might outrun our economic growth and land capacity causing overexploitation, deforestation, erosion, loss of soil fertility, and an overall fall in productivity.

We are on the journey to development, and we are better today than we were before. But we may reverse all of this if we do not put family planning at the forefront of our programs. This would force us to divide the gains we have now with too many people which would create a serious negative impact on access to quality health care and to quality education ultimately oiling the vicious wheel of poverty.

That is why in our Vision 2020 and Economic Development and Poverty Reduction Strategy (EDPRS) for 2008–2012, Rwanda recognizes the impact of rapid population growth on socioeconomic development and is committed to reducing high rates of fertility through family planning.

That is also why the Ministry of Health promotes all type of safe modern methods of family planning recommended by the World Health Organization. The objective is to meet the needs and the preferences of families. This realistic and strategic approach allows us to effectively satisfy the demands for family planning, ensuring that all Rwandan couples who want to space or limit their births have the choice of and access to quality reproductive health services, including a full range of contraceptives consistently available at affordable prices.

These methods comprise, among others, vasectomy for men and tuber ligation for women. The applicants to these definitive methods have to sign a consent form as these non-reversible methods require evidence of voluntary choice after full counseling.

To raise awareness about vasectomy and tuber ligation, the Ministry of Health provides true information to the population through multimedia campaigns. Moreover family planning is discussed during community meetings such as Umuganda and meetings with committees and opinion leaders. For vasectomy, associations of men speak about how they have experienced it, and talk about it to applicants. Vasectomy is a safe and effective permanent contraceptive method that makes men play an active role in controling the family size. When compared with tubal ligation, which usually requires hospitalization and general anesthesia, vasectomy is more simply done under local anesthesia as an outpatient procedure. Men recover quicker from vasectomy (1 hour) than women do from tuber ligation.

We know why people who want to undermine Rwandan development and progress brought the controversy about vasectomy. They say we want to use that tool for bad political purposes against the rights of humanity. But this was a lie, and was aimed to serve bad politicians. Nevertheless I have a question to those who have listened with complacency to that controversy around vasectomy? And why they didn’t assoiate themselves to an identical controversy around tuber ligation – especially since tuber ligation has been performed for so many decades, and is more painful and has more side effects? Was this controversy supported by underground machismo intent?

Wednesday, March 23, 2011

The world has made great progress in the fight against infectious diseases. Rwanda is no exception, and yet there is still a long way to go.

The restitution of the mid-term review of malaria progress, disseminated over the last two weeks, show us we can be proud of our achievements. Results showed that in Rwanda, consultation, hospitalization and deaths due to malaria have decreased by over 60%. These are great results but the major lessons learned during the mid term review is that these gain are fragile; and if we don’t keep up efforts we can roll back the malaria-safe environment we have created for our population.

Concerning the fight against HIV, 78% of pregnant women are correctly using PMTCT services along with 75% of they companions. If we take the extra mile, pediatric HIV may become history. As a pediatrician, this is a dream for me. People living with AIDS are currently being provided with universal access to anti-retroviral therapy (ARTs); ARTs is accessible to all those in need ( around 84000 people). And yet, we need to remain vigilant by continuing to perform well in starting treatment on time to and sensitize people to ensure 100% compliance. This will avoid resistance to drugs and future deaths.

In the area of prevention we have the new Prepex device that we have proved to be safe quick and requiring no anesthesia, no sterile environment and no specialized professionals.

Regarding the fight against tuberculosis: the policy for TB/HIV services has led to great success in detection and treatment. But there must be consisten effort to avoid multi-resistance tuberculosis.

At the community level, Community Health Workers are trained by the Ministry of Health on how to treat at home for gastrointestinal diseases with oral rehydration solution and improved diet as well as pulmonary diseases with Ampiciline.

It is clear we have made much progress in tackling communicable diseases; yet we still we face many challenges in basic hygiene such as washing hands, safe latrines etc. The ongoing hygiene campaigns in Rwanda under the leadership of His Excellency President Paul Kagame will help to go the extra mile for the reduction of morbidity and mortality due to infectious diseases. We are working hard on this.

Tuesday, March 22, 2011

The Government of Rwanda views healthcare as a basic human right. National healthcare delivery is rooted in Rwanda’s commitment to addressing the health concerns of all Rwandans while paying close attention to the most vulnerable persons. This rights-based approach has permeated Rwanda’s health strategy. It is articulated in Rwanda’s Economic Development and Poverty Reduction Strategy, Rwanda’s Vision 2020, and the United Nations’ Millennium Development Goals. The general aim is to engage the nation in a participatory effort to eradicate poverty and the many ills it brings.

This Guide aligns itself with the overall healthcare strategy of the Ministry of Health of Rwanda, specifically in the regulation of development partner initiatives, and in the promulgation of policies and the execution of programs.

Over the past decade, Rwanda has seen under-five mortality drop by half. We have achieved universal access to HIV therapy and now are able to address HIV/AIDS as a chronic disease. More women than ever are delivering their babies in health facilities, and more than 95% of Rwanda’s 11 million people have health insurance. Rwanda’s successes in preventing and treating top killers – malaria, tuberculosis, HIV/AIDS, respiratory infections, and diarrheal diseases – have led to a dramatic increase in life expectancy. With over 400 health centers, 42 district hospitals, and 45,000 community health workers providing care at village level, Rwanda has created a system to bring health care to both its urban and rural populations. The reality that all Rwandans – even the poorest – have access to primary health care represents the strength of the Government and its development partners’ stance on health care and human rights.

Achievements such as these are pivotal. In another decade, Rwanda will undoubtedly continue to see its people living longer, healthier lives. The gross domestic product per capita will also likely increase, and Rwanda’s population will be in better economic shape.

And yet, the current top killers do not account for all of the country’s disease burden. Regretfully, there remains a serious gap in Rwanda’s current health care system. Noncommunicable diseases (NCDs) – probably accounting for about 25% of the national burden of disease – have yet to be addressed in a strategic and systematic way.1 These diseases include cardiovascular disease, cancer, epilepsy, pulmonary disease, and diabetes among others. These are global diseases and yet, more often than not, NCDs are thought to be problems of middle and high-income countries. In such countries, risk factors for NCDs include obesity, tobacco use, and other factors termed poor lifestyle choices. However, in Rwanda, and other developing countries, this is not the case. NCDs are instead linked to malnutrition, infection, congenital abnormalities, toxic environments, and lack of access to basic health care. These are all ultimately caused by poverty. And HIV/AIDS, tuberculosis, malaria and neglected tropical diseases – all diseases endemic to the poorest nations – further contribute to risk factors for NCDs whether treated or untreated.

Rwanda is acutely aware of the need to both treat its population and to protect its population from emerging risk factors that accompany urbanization. Over the next five years, the country foresees itself expanding access to integrated chronic care by building on the existing healthcare platforms established by HIV/AIDS programs. Expanded access and improved options for preventing and treating chronic illnesses and NCDs would have a tremendous impact on morbidity and mortality. Currently, there are many disease-specific advocacy groups in Rwanda fighting for advanced care for conditions such as cardiovascular illness, diabetes, epilepsy, and hemophilia. The challenge for Rwanda is to identify and execute the right set of integrated strategic plans for preventing and treating NCDs. Chronic care integration is one such plan.

Inshuti Mu Buzima (IMB) – the sister organization to the Harvard-affiliated non-profit, Partners in Health (PIH) – was invited to work in partnership with the Ministry of Health of Rwanda at the end of 2003. IMB-PIH has put itself at the service of Rwanda’s vision for health care by devoting itself to the needs of the entire populations of three districts. In particular, it has made a unique contribution in the area of chronic care and NCDs. This approach has led to a joint undertaking between the Ministry of Health and IMB-PIH, including a conference in January 2010, which was focused on how to tackle non-communicable diseases in Rwanda. Through such discussions, chronic care integration has been identified as a central unit of strategic planning to improve the health of the Rwandan population. Other units of planning for NCDs include gynecologic care at district hospitals; improving the quality of generalist physician care at district hospitals; histopathology; cancer care; cancer surgery; cardiac surgery and neurosurgery. Now, in January 2011, Rwanda finds itself equipped with a healthcare system capable of launching chronic care integration; and IMB-PIH finds itself prepared to advise, advance and support the effort.

Many Rwandans could afford the prevention and treatment of uncomplicated cases of common diseases such as malaria or pneumonia, but most could not afford the costs of chronic care of HIV/AIDS, heart disease, diabetes, epilepsy or cancer. Therefore, chronic lifelong treatment and managed care for NCDs must be rooted in a publicly-sponsored, tactical and efficient plan to achieve accessibility and affordability. Already Rwanda has taken steps to tackle some of the prevention issues unique to NCDs, including the improvement of household cooking stoves and access to treatment for streptococcal pharyngitis, among myriad other steps. But we have much work to do. And we implore other low-income countries to take seriously the non-communicable ailments of their patient populations – ailments which most of their citizens must simply endure, because they cannot pay for treatment. Rwanda has made great strides in combatting communicable diseases under the leadership of the Government. The Ministry of Health and our development partners affirm our unwavering dedication to preventing and treating noncommunicable diseases, and making chronic care available to all. It is in this context that I am proud to be collaborating on this publication by Inshuti Mu Buzima - Partners in Health.

Saturday, March 19, 2011

On 16 March, we had the great pleasure of accompanying the Executive Director of UNAIDS, Michel Sidibe on a visit to the Nyamata Distict Hospital in the East Province of Rwanda. We went to see a major revolution in the global fight against HIV, showcasing PrePex - a new non-surgical device for circumcision that allows health care providers to perform each procedure in fewer than 3 minutes without anesthesia, without blood and without suture.

Michel Sidibé traveled to the Nyamata District Hospital after visiting His Excellency President Paul Kagame in Uruguiro. According the New Times – a daily journal in Rwanda – Michel Sidibe said, “President Kagame’s leadership and vision demonstrate clearly that we can produce results when you have commitment at the higher levels.” This applies to the fight against HIV and AIDS.

He spoke with the journalists about the research we have done on Prepex to and affirm our goal to perform 2 million male circumcisions using this new technology nationwide which will revolutionize HIV prevention in Rwanda.

The PrePex device includes an elastic band that fits around an inner ring, to trap the foreskin of the penis, in order to stop the blood flow in the foreskin. The dry foreskin is than removed after one week, (See the blog post March). For the first time, this action can be done on a massive scale for men and will support the prevention of HIV infection not only through the procedure, but also through HIV counseling and testing along with condom distribution and use sensitization of men waiting to be circumcised.

Miche Sidibe said how he was impressed and promise to be the champion of the utilization of this innovation that takes less than 3 minutes to perform and reduces the risk of HIV infection by 66%.

Wednesday, March 16, 2011

The Government of Rwanda views healthcare as a basic human right, and as such, our healthcare delivery model aims to serve all Rwandans, especially the most vulnerable. This rights-based approach is at the root of Rwanda’s health strategy. It is articulated in Rwanda’s Economic Development and Poverty Reduction Strategy, Rwanda’s Vision 2020, and our commitment to the United Nations’ Millennium Development Goals. A major objective of Rwanda is to engage the nation in a participatory effort to eradicate poverty and the many ills it brings.

Over the past decade, Rwanda has seen under-five mortality drop by half. We have achieved universal access to HIV therapy and now are able to address HIV/AIDS as a chronic disease.

More women than ever are delivering their babies in health facilities, and more than 95% of Rwanda’s 11 million people have health insurance. Rwanda’s successes in preventing and treating top killers – malaria, tuberculosis, HIV/AIDS, respiratory infections, and diarrheal diseases – have led to a dramatic increase in life expectancy.

With over 400 health centers, 40 district hospitals, and 45,000 community health workers providing care at village level, Rwanda has created a system to bring health care to both its urban and rural populations. This system has improved financial and geographic access to health services to all Rwandans, even the poorest. And our accomplishments represent the strength of the Government’s stance on health care and human rights and the support of its development partners.

Achievements such as these are pivotal. In another decade, Rwanda will without any doubt continue to see its people living longer and healthier lives. The gross domestic product per capita will also likely increase because of a healthier population, and Rwanda’s population will be in better economic shape.

However, by fighting the current top killers we are only able to increase the life expectancy to approximately 54 years as infectious diseases do not account for all of the country’s morbidity and mortality burden. Our service delivery still has serious gaps as noncommunicable diseases (NCDs) which probably account for about 25% of the national burden of disease according to World Health Organisation have yet to be addressed in a strategic and systematic way.1

These diseases include cardiovascular disease, cancer, epilepsy, pulmonary disease, and diabetes among others. These are global diseases and yet, more often than not, NCDs are thought to be problems of middle and high-income countries. I want to stand strongly against that. If in the North, risk factors for NCDs include obesity, tobacco use, and other factors called poor lifestyle choices, tobacco and nutritional factors impact also the health of our population. Tobacco because the quality of the cigarettes in Africa is not controlled and it contain more toxics. The nutrition factors are important but more because of undernutrition than overnutrition. But if we don’t tackle life style and nutrition now, when our economy will grow, overnutrition will replace undernutrition as the main cause of malnutrition.

In general, NCDs in the developing world are linked to malnutrition, infection, congenital abnormalities, toxic environments, and lack of access to health care services required to tackle NCDs early enough. All of these factors are ultimately exacerbated by poverty. On top of that, HIV/AIDS, tuberculosis, malaria and neglected tropical diseases contribute seriously to increasing the risk factors for NCDs whether treated or untreated.

Rwanda is aware of the need to both treat its population and to protect its population from emerging risk factors that accompany urbanization and we have started to work on it. Over the next five years, the country anticipates expanding access to integrated chronic care by building on the existing healthcare platforms established by programs fighting infectious diseases.

Currently, there are many disease-specific advocacy groups in Rwanda and in the world fighting for advanced care for conditions such as cardiovascular illness, diabetes, epilepsy, and hemophilia. The challenge for a country like Rwanda is to coordinate those efforts, and identify and execute the right set of integrated strategic plans to prevent and treat NCDs in a holistic manner. This is important as infectious diseases, chronic diseases, non-communicable diseases, hurt the same members of our communities; and also, service will be delivered by the same health professionals in the same health centers across all illnesses. We talk about human as an entity, and so infectious disease, NCDs and chronic care has to be integrated to serve those human individuals without making them lose time and continium of care. For example, when someone has a cardiac disorder and gets malaria and suffers from cancer – we must make sure that all care should be should be timely given. And because of equity, and equality in access to care, we need to do our best to provide quality integrated care where people are living.

Currently, many Rwandans are able to afford the prevention and treatment of uncomplicated cases of common diseases such as malaria or pneumonia, but most cannot afford the costs of chronic care of HIV/AIDS, heart disease, diabetes, epilepsy or cancer. Therefore, chronic lifelong treatment and managed care for NCDs must be derive from a publicly-sponsored, tactical and efficient plan to achieve accessibility and affordability. Already Rwanda has taken steps to tackle some of the prevention issues unique to NCDs, including the improvement of household cooking stoves and access to treatment for streptococcal pharyngitis, among myriad other steps. But we have much work to do. We will never achieve our development goals if we don’t take seriously the non-communicable illnesses of our patient populations – illnesses which most of our citizens must simply endure since they cannot pay for treatment. Without decreasing the attention we currently have on combating communicable diseases, we affirm our constant dedication to preventing and treating noncommunicable diseases, and making chronic care available to all.

Recently the three-day international conference on Community health was organised in Kigali by the Ministry of Health. The theme was “The role of community health in Strengthening Health Systems” This was the first conference of its kind.

In Rwanda in each village (100 to 200 households) elects three volunteers to act as CHWs for the general population – a binome comprising of a man and a women for general diseases and a women as assistant maternal to follow antenatal care, women after delivery and children below 9 months Once elected the CHWs are trained by the Ministry of Health throughout the country to deliver quality of services and to monitor health at village level and to refer sick patients to the nearest health facility. By sensitizing the local village and making themselves available, they improve access to care. Because each community votes on two women to serve the village as CHWs, becoming a CHW is now a position of respect, raising gender equity throughout Rwanda.

The community health workers are an important component of health services, by bridging between the need of services service delivery, social and economic development, and the Millennium Development Goals (MDGs). They strength the health system and avoid the population to take long walks to the nearest health centres.

Community health workers reinforce the six building blocks of WHO . The first one: Good health services – as they are trained and supervised by health professional at sector level. The second one: A well-performing health workforce – the 3 CHWs per village (45000 in the country) increase service delivery. The third one: A well-functioning health information system – the report provided by the community health workers. : The fourth one Equitable access to essential medical products, vaccines and technologies – CHWs diagnose and treat malaria, diarrhea pneumonia, they give family planning drugs, they facilitate outreach for vaccination, and sensitise for HIV testing. The fifth: A good health financing system as these volunteers are compensated only by creating cooperatives in their sector receiving money for services they provide to their village they generate community economic growth through health activities. The last one Leadership and governance – as elected people they are role models.

Access to care in resource-constrained countries face financial, infrastructural, and geographical barrier. Community health workers (CHWs) are a solution for overcoming those and improve access to health in rural communities. By using CHWs, with their approach to health at the community level, Rwanda hopes to solve 80% of health problems in the country.

All activities of CHWs are included in the health reporting system through reports that they give to the Executives Secretary of each Sector, who in turn report activities to the Director of Health at the District level. These report are sent to the Ministry under the responsibility of Mayors. That and the election guaranty the local and community ownership

There is strong evidence in favour of MC to reduce HIV infection and other STI. In Rwanda, where adult HIV prevalence is 3%, MC is not a traditional practice. To inform policy and programmatic decisions in relation to introducing MC, the Rwanda National AIDS Commission modelled cost and effects of MC at different ages. This study was needed given that the MC debate in Southern Africa had focused primarily on MC for adults.

A cost-effectiveness model was developed and applied to three hypothetical cohorts in Rwanda: newborns, adolescents and adult men. Effectiveness is defined as the number of HIV infections averted, and is the product of the number of people susceptible to HIV infection in the cohort, the HIV incidence rate at different ages and the protective effect of MC; discounted back to the year of circumcision and summed over the life expectancy of the circumcised person. Direct costs were based on interviews with experienced health-care providers to determine inputs involved in the procedure (from consumables to staff time) and related prices. Other costs included training, patient counselling, treatment of adverse events and promotion campaigns and were adjusted for the averted lifetime cost of health care (ART, OI, laboratory tests). One-way sensitivity analysis was performed for different values of the main inputs of the model and the thresholds at which each intervention is (a) no longer cost-saving and (b) at which it costs more than one GDP/capita/life year gained were calculated.

Neonatal male circumcision is less expensive than adolescents and adult male circumcision (15 USD instead of 59 USD per procedure) and is cost-saving (the cost effectiveness ration is negative); even though savings from infant circumcision will be realized later in time. The cost per infection averted is 3,932 USD for adolescent MC and 4,949 USD for adult MC. Results for infant MC appear robust. Infants MC remains highly C-E for a reasonable amount of changes in the base case scenario. Adolescent male circumcision is highly cost-effective for the base case scenario but no longer so for very small changes in the input variables. Adults MC is neither cost-saving nor highly cost-effective when considering only the direct benefit for the circumcised man. Additionally, infant MC can be easily integrated into existing health services (i.e. neonatal visits and vaccination sessions) and has a better potential to achieve the very high coverage over time of the population required for maximal reduction on HIV incidence, than adolescent and adult circumcision.

African leaders and development partners should stop managing the HIV response as an emergency issue and release themselves from a one-year or even a five-year planning perspective to focus on sustainable long-term choices for countries. The study suggests that Rwanda should be simultaneously scaling up circumcision across a broad range of age groups, with highest priority to the very young. In the presence of infant MC, adolescent and adult MC should become a sort of “catch up” campaign that would be needed at the start of the program but would then become superfluous over time.

I had the fantastic opportunity to participate in the Government of Rwanda sponsored study to test the PrePex System, a new device and methododology for rapid adult male circumcision deployment in resource-limited settings.

The study, in line with the World Health Organization’s and UNAIDS’s recommendations to encourage voluntary male circumcision, began in March 2010 and proved the safety and efficacy of the device.

Many studies have proven that circumcised men in high risk areas, including sub-Saharan Africa, reduce their risk of HIV infection by about 60%.

The existing surgical techniques and devices require time of highly trained health professionals, surgical settings and and out of work time for patients to recover. This limits the ability of many African countries to scale up male circumcision initiatives given the regional shortage of health professionals and medical infrastructure and the economic impact of the patient time to recover.

Because we have the conviction that all need to be done to protect our population in the context of the fight against HIV, the Ministry of Health in Rwanda has the national goal to decrease its HIV incidence rate by 50% by circumcising two million adults in two years but so far Current male circumcision efforts have been a drop in the ocean compared to the masses required.

That is why the Ministry of Health of Rwanda, in partnership with the PrePex Compagny a social private entreprise, undertake researches on viable non-surgical male circumcision method. In that context the Government of Rwanda sponsored second clinical study (N°:NCT01284088 on ClinicalTrials.gov) which is showing very promising preliminary results on the cost effectiveness of the use of this new device for HIV prevention, as well as reaffirming our knowledge of the safety and efficacy.http://clinicaltrials.gov/ct2/show/NCT01150370.

Except for a few hours on the day of deployment, patients circumcised with the PrePex device required no additional recovery days for pain or wound management. This has major economic ramifications for a country like ours, where rural men work their fields and cannot afford to lose so many days of work for a preventative procedure.

The UN press agency wrote about this great development - click here to see the story.

I wrote the following blog post, "The Role of King Faisal Hospital Today," in 2007. I am sharing it on my new blog as it has not been previously published, but some of the information is out-of-date. It does accurately describe the vision of the Ministry of Health for King Faisal Hospital and its role in our health system.

All sectors of the Rwandan Government are dedicating substantial efforts to achieving our national development objectives. Together with the support of partners from around the world, the Government has strived to endow the country with innovative tools and programs that aim to make the necessary changes in the health sector to enlarge the range of quality services given to the population. The programs in question are complementary and have specific objectives. Through this support, Community-Based Health Insurance, RAMA, the decentralization of sanitary systems, the equipment of district hospitals, referral hospitals, and King Faisal Hospital in Kigali have become essential pillars of the development plan of the health sector.

Among the health sector’s various achievements, one of the most impressive is that more than one million Rwandans now have community-based health insurance and all Rwandan civil servants are now covered by RAMA as of late 2007. Among other resources available to public programs, we now have substantial funds for the fight against HIV/AIDS that are being used to control the epidemic in a way that builds the national health sector, as well as funds for new equipment in district hospitals, referral hospitals, and health centers across the country. These achievements have benefited the whole population.

At the same time, thanks to the Government's advocacy in negotiating with partners across many continents, King Faisal Hospital has increased its capacity to provide services to the country’s sick. King Faisal Hospital can now offer very specialized abdominal surgery by laparoscopy as well as other state-of-the-art technology in orthopedics, orthodontic care, and ophthalmology services. More specialties will continue to join the array of services offered on a regular basis.

Beyond this immediate improvement in the spectrum of available services, King Faisal Hospital has a mission of training that aims to assure capacity building of Rwanda’s medical students, general practitioners, and specialists. With the support of the Ministry of Health and the United Nations Development Program, the hospital now has a telemedicine center that allows exchanges and continuing education programs through linking King Faisal to teaching hospitals around the world. Our population, our medical students, and our physicians are increasingly benefiting from it. Other strong partnerships have been created to allow cardiac catheterization and open heart surgery, treatments usually outside of the financial means of most Rwandans. Now, thanks to solidarity on the part of Australian, American, and Belgian physicians who come on surgical and capacity-building trips, the average Rwandan can benefit from these services at King Faisal Hospital.

Thanks to Community-Based Health Insurance, RAMA, and the Ministry of Health’s national referral system, patients referred through the normal process can receive specialized care offered King Faisal at costs comparable to care offered at CHUK. A patient is generally referred from a health center to a district hospital to a referral hospital if necessary. These referral hospitals can then refer to King Faisal Hospital for care that is not available elsewhere. In the case of severe medical emergencies, a patient can be referred directly to King Faisal Hospital without progressing through the standard tiered referral process.

Referral to King Faisal Hospital is free for the poorest Rwanda if they have the requisite administrative documents from ubudehe. As a result of this social justice-based access policy, the more King Faisal Hospital has high-level quality and varied care, the better the Rwandan population will be taken care of. King Faisal Hospital also allows our tourists or our investors who spend time in Rwanda to be assured that they will have access to high-quality health care should the need arise. This is a great way to attract and retain investors.

We have a long way to go, but the Government along with its partners has put in place a system so that all can receive affordable and quality care, even for the poorest citizens because the Government pays for them. Rwanda has a national goal of becoming a middle-income country within the coming decades. Therefore, it is essential to sustain efforts to assure access to high-quality health care to all.